Nokea
A 72-year-old man has been brought to his primary care provider by his daughter, who claims that he has been experiencing uncharacteristic lapses in memory. What principle should underlie the nurses assessment and management of this patient?
- A. Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic.
- B. Lapses in memory in older adults are considered benign unless they have negative consequences.
- C. Gradual increases in confusion accompany the aging process.
- D. Thorough assessment is necessary because changes in cognition are always considered to be pathologic.
Correct Answer: D
Rationale: Cognitive changes in older adults are not assumed normal and require thorough assessment to rule out pathology like dementia. Memory and judgment typically remain intact with aging.
You may also like to solve these questions
The nurse caring for an 80 year-old patient knows that she has a pre-existing history of dulled tactile sensation. The nurse should first consider what possible cause for this patients diminished tactile sensation?
- A. Damage to cranial nerve VIII
- B. Adverse medication effects
- C. Age-related neurologic changes
- D. An undiagnosed cerebrovascular accident in early adulthood
Correct Answer: C
Rationale: Aging reduces sensory receptor density, dulling tactile sensation. Cranial nerve VIII affects hearing, medications may cause other effects, and an old CVA is less likely without evidence.
A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patients foot is abruptly dorsiflexed, it continues to beat two to three times before settling into a resting position. How would the nurse document this finding?
- A. Rigidity
- B. Flaccidity
- C. Clonus
- D. Ataxia
Correct Answer: C
Rationale: Clonus is characterized by rhythmic muscle contractions, such as foot beating after dorsiflexion, indicating hyperactive reflexes. Rigidity is increased muscle tone, flaccidity is lack of tone, and ataxia is uncoordinated movement.
The patient in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a postlumbar puncture headache, what is the nurses most appropriate action?
- A. Position the patient prone.
- B. Position the patient supine with the head of bed flat.
- C. Position the patient left side-lying.
- D. Administer acetaminophen as ordered.
Correct Answer: A
Rationale: Prone positioning after lumbar puncture minimizes cerebrospinal fluid leakage, reducing headache risk. Supine or side-lying positions are less effective, and acetaminophen is not a preventive measure.
A patient is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the patients bladder?
- A. The parasympathetic nervous system causes urinary retention.
- B. The parasympathetic nervous system causes bladder spasms.
- C. The parasympathetic nervous system causes urge incontinence.
- D. The parasympathetic nervous system makes the bladder contract.
Correct Answer: D
Rationale: Parasympathetic stimulation contracts the bladder, promoting urination. Retention, spasms, or incontinence are not direct parasympathetic effects.
A patient had a lumbar puncture performed at the outpatient clinic and the nurse has phoned the patient and family that evening. What does this phone call enable the nurse to determine?
- A. What are the patients and familys expectations of the test
- B. Whether the patients family had any questions about why the test was necessary
- C. Whether the patient has had any complications of the test
- D. Whether the patient understood accurately why the test was done
Correct Answer: C
Rationale: Post-lumbar puncture follow-up checks for complications like headaches or infection. Expectations and understanding should be addressed before the procedure.